New Co-Pay Coupons Rules: Another Blow to Patients

One benefit of using co-pay coupons will soon disappear, according to new federal guidance.

Patients often use co-pay coupons to afford innovative, yet expensive, drugs such as those that treat cystic fibrosis, cancer or hepatitis.  And the majority of medications with co-pay coupons have no generic alternative.  

In addition to helping pay patients’ up-front pharmacy bill, the coupons also historically counted toward a patient’s annual deductible.  This helped patients reach the threshold when insurance begins covering the cost of medications. Then the rules began to change.  

Insurers began implementing what are known as co-pay accumulator programs.  Patients can still use co-pay coupons, but the programs don’t allow the value to help pay down patients’ deductibles.  This left some patients, particularly those with high-deductible health plans who needed costly medications, with unsurmountable medical bills – an ugly “co-pay surprise.”  Nearly 40% of large employers have them in place and another 15% “will have them” or “are considering putting them in” by 2021-22, according to a National Business Group on Health survey.

Earlier this year, the Centers for Medicare and Medicaid Services responded to the patient impact of these programs by issuing guidance that limited the practice to only instances where a generic alternative existed.  The decision signaled a positive turn in policy.  

But last month conflicting federal rules prompted CMS to make yet another decision.  Now, starting in 2020, insurers can exclude the value of co-pay coupons from counting toward a patient’s deductible, regardless of whether a generic alternative exists. 

The guidance is a serious blow to patients.  

Carl Schmid of The AIDS Institute called the policy shift “disappointing.”  The change will increase patients’ cost sharing, “which is completely opposite of the Administration’s desire to lower prescription drug costs for patients,” he pointed out.

Without co-pay coupons, many patients won’t be able to afford their medication.  Others may have to sacrifice daily essentials or financial security to cover the entire cost of their deductible, which can require patients to pay thousands of dollars, sometimes in a single month.

It’s understandable that payers want to control rising health care costs.  But keeping patients from their physician-prescribed medication is short-sighted.  Without access to the treatments and therapies that allow patients to keep their conditions well managed, they could become sicker.  This then leads to additional health care utilization and medications – creating unnecessary pain for patients and their families and, ironically, more of the expenses that payers were trying to control.

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